1578627782 NPI number — DAVID M. HEADLEY, M.D. PA

Table of content: (NPI 1578627782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578627782 NPI number — DAVID M. HEADLEY, M.D. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID M. HEADLEY, M.D. PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578627782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 676
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT GIBSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39150-0676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-437-3323
Provider Business Mailing Address Fax Number:
601-437-8499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT GIBSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39150-2024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-437-3323
Provider Business Practice Location Address Fax Number:
601-437-8499
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEADLEY
Authorized Official First Name:
JEZELLE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
601-437-3323

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  09133 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DN3465 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 09015175 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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